Health insurance markets and income inequality: findings from an international health policy survey

Health Policy. 2000 Mar;51(2):67-85. doi: 10.1016/s0168-8510(99)00084-6.


Objective: To assess disparities in access to health care, financial burden of medical bills and perceived quality of care between those with above average incomes and those with below average incomes in five nations and to examine the relationship inequities in care experiences to health insurance coverage.

Design: Cross-sectional analysis of a random survey of adults in 1998.

Subjects: 5059 adults ages 18 and over in five English-speaking countries: Australia, Britain, Canada, New Zealand and the United States (approximately 1000 per country).

Main outcome measures: Failure to receive needed care, difficulty getting care, waiting for elective surgery, problems paying medical bills, failure to fill prescriptions due to cost, perceived quality of medical care received and of most recent doctor visit.

Results: There were two to three-fold differences between those with above and below average incomes on measures of access to care in the US, Australia and New Zealand. In Britain and Canada indicators of access of to care were similar for the two income groups. Problems paying medical bills were most prevalent in the US, yet significant differences by income also existed in Australia, Canada and New Zealand. Those with below average incomes were more likely to have not filled a prescription due to cost in Australia, Canada, New Zealand and the US, with gaps by income most severe in the US. Ratings of quality of doctor visit were significantly different for the two income groups in the US, but not other countries.

Conclusions: The analysis finds striking differences among countries in the relative equity of health care experiences. In general, care experiences are more unequal in three countries such as the US, Australia and New Zealand where systems have relatively greater reliance on private health insurance and markets. Greater inequality in care experiences is also associated with more divided public opinion regarding the need for system reform and the direction of recent policy changes. In Canada and Britain where care experiences are more equal of the health system are similar across income groups. Reliance on private insurance and patient user fees appears to lead to more divided views of the overall health system as well as inequity in access to care.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Attitude to Health
  • Australia
  • Canada
  • Cost Sharing
  • Health Care Surveys*
  • Health Policy / economics*
  • Health Services Accessibility / economics
  • Health Services Accessibility / statistics & numerical data*
  • Health Status
  • Humans
  • Income / classification
  • Insurance, Health / statistics & numerical data*
  • New Zealand
  • Quality of Health Care
  • Social Justice
  • United Kingdom
  • United States